<?php echo $header;?>


<div id="sign-up-page">
	<div class="container">
		<h1><?php echo $LANG["WBS_REGF_NEW_ACCOUNT"];?></h1>
	<div id="sign-up-form" class="col-md-6">
<div class="form">  

                    <div class="input-icon col-lg-12 col-xs-12 col-sm-12 col-md-12 right input-group margin-bottom-20 margin-top-20">
					<label><?php echo $LANG["WBS_REGF_NAME"];?></label>
					<div class="row">
                        <div class="col-lg-6 col-xs-6 col-sm-6 col-md-6">
							<input id="fname" type="text" class="form-control" placeholder="<?php echo $LANG["WBS_REGF_FNAME"];?>">
						</div>
                        <div class="col-lg-6 col-xs-6 col-sm-6 col-md-6">
							<input id="lname" type="text" class="form-control" placeholder="<?php echo $LANG["WBS_REGF_LNAME"];?>">
						</div>
					</div>
                    </div>

                    <div class="input-icon col-lg-12 col-xs-12 col-sm-12 col-md-12 right input-group margin-bottom-20">
					<label for="email"><?php echo $LANG["WBS_REGF_EMAIL"];?></label>
                        <input id="email" type="text" class="form-control" placeholder="<?php echo $LANG["WBS_REGF_EMAIL"];?>">
                    </div>

                    <div class="input-icon col-lg-12 col-xs-12 col-sm-12 col-md-12 right input-group margin-bottom-20">
					<label><?php echo $LANG["WBS_REGF_PW"];?></label>
                        <input id="password" type="password" class="form-control" placeholder="<?php echo $LANG["WBS_REGF_PW"];?>">
                    </div>   

                    <div class="input-icon col-lg-12 col-xs-12 col-sm-12 col-md-12 right input-group margin-bottom-20">
					<label><?php echo $LANG["WBS_REGF_CPW"];?></label>
                        <input id="cpassword" type="password" class="form-control" placeholder="<?php echo $LANG["WBS_REGF_CPW"];?>">
                    </div>

						<div class="row">
							<div class="col-lg-12 col-xs-12 col-sm-12 col-md-12"><div id="password-err"></div></div>
						</div>  

                    <div class="input-icon col-lg-12 col-xs-12 col-sm-12 col-md-12 right input-group margin-bottom-20">
					<label><?php echo $LANG["WBS_REGF_BIRTHDAY"];?></label>
					<div class="row">
                        <div class="col-md-4">
							<select id="month" class="form-control">
								<option	value="0"><?php echo $LANG["WBS_REGF_MONTH"];?></option>
								<option	value="1"><?php echo $LANG["WBS_REGF_MONTH_1"];?></option>
								<option	value="2"><?php echo $LANG["WBS_REGF_MONTH_2"];?></option>
								<option	value="3"><?php echo $LANG["WBS_REGF_MONTH_3"];?></option>
								<option	value="4"><?php echo $LANG["WBS_REGF_MONTH_4"];?></option>
								<option	value="5"><?php echo $LANG["WBS_REGF_MONTH_5"];?></option>
								<option	value="6"><?php echo $LANG["WBS_REGF_MONTH_6"];?></option>
								<option	value="7"><?php echo $LANG["WBS_REGF_MONTH_7"];?></option>
								<option	value="8"><?php echo $LANG["WBS_REGF_MONTH_8"];?></option>
								<option	value="9"><?php echo $LANG["WBS_REGF_MONTH_9"];?></option>
								<option	value="10"><?php echo $LANG["WBS_REGF_MONTH_10"];?></option>
								<option	value="11"><?php echo $LANG["WBS_REGF_MONTH_11"];?></option>
								<option	value="12"><?php echo $LANG["WBS_REGF_MONTH_12"];?></option>
							</select>
						</div>
                        <div class="col-md-4">
							<select id="day" class="form-control">
								<option	value="0"><?php echo $LANG["WBS_REGF_DAY"];?></option>
								<?php for ($i = 1; $i <= 31; $i++) { ?>
									<option	value="<?php echo $i;?>"><?php echo $i;?></option>
								<?php } ?>
							</select>
						</div>
                        <div class="col-md-4">
							<select id="year" class="form-control">
								<option	value="0"><?php echo $LANG["WBS_REGF_YEAR"];?></option>
								<?php for ($i = 1934; $i <= date("Y"); $i++) { ?>
									<option	value="<?php echo $i;?>"><?php echo $i;?></option>
								<?php } ?>
							</select>
						</div>
					</div>
                    </div>

                    <div class="input-icon col-lg-12 col-xs-12 col-sm-12 col-md-12 right input-group margin-bottom-20">
					<label><?php echo $LANG["WBS_REGF_LOCATION"];?></label>
	<select id="location" name="location" class="form-control">
		<option value=""><?php echo $LANG["WBS_REGF_COUNTRY_SELECT"];?></option>
			<?php if ( !empty ( $countries ) ) { ?>
			<?php foreach($countries as $country): ?>
				<option value="<?php echo $country['country_id'];?>"><?php echo $country['country_name'];?></option>
			<?php endforeach; ?>
			<?php } ?>
	</select>
                    </div>





                    <div class="input-group margin-bottom-20">
                        <div class="checkbox-list"><label class="checkbox"><input id="terms" type="checkbox"> <?php echo $LANG["WBS_REGF_TERMS_AGREE"];?></a></label></div>
                    </div>       
						<div class="row">
							<div class="col-lg-12 col-xs-12 col-sm-12 col-md-12"><div id="terms-err"></div></div>
						</div>       

						<div class="row">
							<div class="col-lg-12 col-xs-12 col-sm-12 col-md-12"><div id="register-loader"></div></div>
						</div>

                    <div class="row">
                        <div class="col-lg-12 col-xs-12 col-sm-12 col-md-12 col-sm-12 right">
                            <button id="ad-register" type="submit" class="btn blue-btn"><?php echo $LANG["WBS_REGF_SUBMIT"];?></button>
                        </div>
                    </div>

                </div>
	</div>

	</div>
</div>




<?php echo $footer;?>